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Genital ulceration does not increase HIV-1 shedding in cervical or vaginal secretions of women taking antiretroviral therapy
  1. Susan M Graham1,2,3,4,
  2. Linnet Masese1,2,
  3. Ruth Gitau2,
  4. Barbra A Richardson1,
  5. Kishor Mandaliya5,
  6. Norbert Peshu3,
  7. Walter Jaoko2,
  8. Jeckoniah Ndinya-Achola2,
  9. Julie Overbaugh6,
  10. R Scott McClelland1,2
  1. 1University of Washington, Seattle, Washington, USA
  2. 2University of Nairobi, Nairobi, Kenya
  3. 3Kenya Medical Research Institute, Kilifi, Kenya
  4. 4University of Toronto, Toronto, Ontario, Canada
  5. 5Coast Provincial General Hospital, Mombasa, Kenya
  6. 6Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
  1. Correspondence to Dr Susan M Graham, University of Washington, Box 359909, 325 Ninth Avenue, Seattle, WA 98104-2499, USA; grahamsm{at}


Objectives Genital ulcer disease (GUD) is associated with increased HIV-1-RNA shedding in antiretroviral therapy (ART)-naive women. The effect of GUD on HIV-1 shedding among ART-treated women is not known. The objective of this study was to test the hypothesis that genital ulcerations increase genital HIV-1-RNA shedding in women receiving ART.

Methods Eligible women initiated ART and attended monthly visits with inspection for genital lesions and collection of genital swabs. GUD cases diagnosed after 2 months or more on ART were included for analysis and served as their own controls. HIV-1 RNA was quantitated in specimens collected before, during and after GUD for all cases. The lower limit of quantitation was 100 HIV-1-RNA copies/swab. Using the pre-GUD visit as the reference, the detection of genital HIV-1 RNA before versus during and after GUD episodes was compared.

Results 36 women had GUD episodes after ART initiation. HIV-1 RNA was detected before, during and after GUD in cervical secretions from four (11%), one (3%) and six (17%) women, respectively, and in vaginal secretions from three (8%), four (11%) and four (11%) women, respectively. After adjustment for time on ART, there was no difference in the detection of cervical HIV-1 RNA before versus during GUD (adjusted OR 0.22, 95% CI 0.04 to 1.23). Likewise, GUD did not increase HIV-1 detection in vaginal secretions (adjusted OR 1.32, 95% CI 0.29 to 5.92).

Conclusions GUD did not significantly increase cervical or vaginal HIV-1 shedding. The results suggest that ART maintains its effectiveness for genital HIV-1 suppression despite GUD episodes.

  • Antiretroviral therapy
  • genital ulcer
  • HIV infection
  • women

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  • Funding This study was supported by funding from the National Institutes of Health (NIH), grants R01 AI058698 and K23 AI69990 (SMG). Additional support for the Mombasa Field Site was received from the University of Washington Center for AIDS Research (CFAR), an NIH-funded programme (P30-AI027757), which is supported by the following NIH Institutes and Centers (NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NCCAM). The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethical review committees of the Kenya Medical Research Institute, the University of Washington and the Fred Hutchinson Cancer Research Center approved the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.